EQRM FORM
July 2008
Equal Opportunities Recruitment Monitoring Form – Strictly Confidential
The National Treatment Agency (NTA) is committed to promoting fairness and eliminating discrimination from recruitment and selection
practices. We will ensure that no job applicant or employee received less favourable treatment either directly or indirectly, on the
grounds of age, race, disability, gender, marital status, religion or faith or sexual orientation.
To monitor and audit the effective delivery of this commitment, the NTA requires all applicants to provide information asked for in this
monitoring form. This will only be used for this purpose, will form no part of the interview process and will be treated in strict
confidence.
The form will be detached from your application form and transferred to our Human Resources database to help monitor the diversity of
applications we receive. This will enable us to develop appropriate policies and procedures in respect of diversity and equal
opportunities.
Name:
Date:
Position applied for:
Location:
Where did you learn
of this post?:
NTA Website
NHS Job Website
Internal Vacancy Bulletin
Newspaper (please specify………………………..)
1.
Gender:
2.
Date of birth:
3.
Marital status:
Male
Female
Married
Single
Other (please specify……………………………)
Divorced
Other
(Please specify …………………………)
4.
Nationality:
5.
How would you describe your ethnic origin?
White
A
British
Black or black British
M Caribbean
B
Irish
N
African
C
Any other white background
P
Any other black background
Mixed
D
White and black Caribbean
Other ethnic groups
R Chinese
E
White and black African
S
F
White and Asian
G
Other mixed background
Please specify ……………………………..
Z
Asian or Asian British
H
Indian
J
Pakistani
K
Bangladeshi
L
Other Asian background
Please specify ………………………………
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Other ethnic groups
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Not stated
6.
Disability is defined by the Disability Discrimination Act as;
A physical or mental impairment, which has a substantial and long-term adverse effect on a person’s ability to carry out normal
day-to-day activities. The disability could be physical, sensory or mental and must be expected to last at least 12 months.
Are you a disabled person as defined by the Disability Discrimination Act?
7.
How would you describe your religion or belief?
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
None
Prefer not to say
Other (please specify ……………………………………………………………………)
8.
Yes
What of the following describes your sexual orientation?
Bi-sexual
Gay
Other
Prefer not to disclose
Heterosexual
Thank you for completing this form. Please return it with your application.
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Lesbian
No